Emergent TEVAR for Acute Aortic Syndromes Involving the Descending Thoracic Aorta
Bradley G. Leshnower, Ravi K. Veeraswamy, Yazan M. Duwayri, Edward P. Chen.
Emory University School of Medicine, Atlanta, GA, USA.
OBJECTIVE: Traditional surgical treatment of acute aortic syndromes involving the descending thoracic aorta (DTA) requires open aortic exposure with the use of cardiopulmonary bypass and is associated with high morbidity and mortality. Thoracic endovascular aortic repair (TEVAR) offers a rapid, minimally invasive solution to these lethal presentations. We reviewed our experience with TEVAR for the treatment of acute DTA pathology.
METHODS: From 01/2011-12/2013, 110 TEVAR procedures were performed at a single US academic institution. 45 (41%) patients underwent emergent TEVAR for treatment of acute DTA pathology. Traumatic aortic transections were excluded from this review.
RESULTS: The mean age of all patients was 60 ± 13 years. 8 (18%) patients required a zone 2 landing, with a single patient receiving a carotid-subclavian bypass. DTA pathology treated with emergent TEVAR consisted of: acute complicated DeBakey III aortic dissection (n=26), symptomatic penetrating aortic ulcer with intramural hematoma (n=10), ruptured aneurysm (n=5), aortobronchial fistula (n=3), and rapidly expanding pseudoaneurysm (n=1). In the dissection population, 11 patients presented with malperfusion, of which 3 required additional branch vessel stenting to restore end-organ perfusion. TEVAR was delivered via femoral (n=42), iliac (n=2) and direct abdominal aortic (n=1) access. 4 (8.9%) patients suffered in-hospital mortality. 3 patients died of aortic rupture distal to the stent graft and one patient died of massive pulmonary embolism. 2 of the 3 patients who were paraplegic in the postoperative period initially presented with paraplegia, which was unresolved after TEVAR. A single patient suffered transient paraperesis, which was completely resolved with CSF drainage. 1 patient suffered a postoperative stroke and 1 patient required new onset dialysis. 7(16%) patients, all of whom presented with dissection, required reintervention during the study period. Of these 7 patients, 3 patients underwent proximal aortic surgery, 1 patients required open DTA replacement, and 3 patients required further endovascular procedures.
CONCLUSIONS: Emergent intervention involving the DTA can be performed using TEVAR with acceptable operative risk. Patients with acute DeBakey III dissection must be monitored closely as early reintervention is often warranted. These data suggest that TEVAR is a highly effective treatment strategy for acute aortic syndromes of the DTA.
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